Services
Utilization Management Services
Overview
Our utilization management (UM) services help healthcare organizations provide patients with appropriate, efficient, and cost-effective medical care by evaluating the medical necessity and efficiency of services and procedures through prospective, concurrent, and retrospective reviews. Our comprehensive program ensures patient care is consistent with current medical standards and that resources are allocated effectively. By utilizing MCG and InterQual criteria, we confirm that cases meet established guidelines and determine the appropriate length of stay.
We maintain clear and effective communications with payers and internal teams as needed, identifying, and mitigating potential risks such as overutilization. We analyze medical necessity denials by performing utilization reviews and work with your clinical documentation and clinical denial and appeal teams to remediate root causes. Our UM services contain healthcare costs by ensuring the appropriate level of care, preventing unnecessary procedures, and optimizing treatment plans. Through these multifaceted efforts, our UM services enhance patient outcomes, streamline resource utilization, uphold high standards of care, and drive excellence in healthcare delivery.
SERVICES PROVIDED
Efficiently manage resources, maintain high-quality patient care, and navigate complex requirements. Utilization management services provided include:
- Concurrent and retrospective utilization reviews.
- Extend inpatient authorizations, for continued stays, to minimize net revenue leakage.
- Review of patient charts to validate medical necessity for procedures per payer contracts.
- Recommend alternate care options that may be more appropriate.
BENEFITS
Increased Cost Efficiency
Evidence-based guidelines ensure the effective use of medical services, procedures, and facilities, helping hospitals manage resources efficiently.
Enhanced Patient Care
Collaborate with physicians for complete and accurate documentation and navigate Medicare and Medicaid participation requirements, ensuring patients receive appropriate and medically necessary care.
Improved Regulatory Compliance
Prevent revenue losses associated with high readmission rates and penalties to reduce the risk of denials and audits to enhance hospital efficiency and secure better financial health.
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Clinical Documentation Integrity Services
A combination of retrospective, prospective, and concurrent reviews of clinical documentation provides precision and specificity in clinical documentation tailored to inpatient and ambulatory settings.